Levande.

correction orders using federal software. Please disregard the heading of the fourth column that states, "Provider's Plan of Correction." A plan of correction is not required. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Kelly Thorson, Supervisor State Evaluation Team Email: Kelly.Thorson@state.mn.us Telephone: 320-223-7336 Fax: 1-866-890-9290 HHH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 PRINTED: 06/18/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 33435 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 SL33435016-0 Minnesota Department of Health is documenting the State Correction Orders On May 5, 2025, through May 7, 2025, the using federal software. Tag numbers have survey at the above provider. At the time of the Statutes for Assisted Living Facilities. The survey, there were 68 residents; 53 receiving assigned tag number appears in the services under the Assisted Living with Dementia far-left column entitled "ID Prefix Tag." The Care license. As a result of the survey, the state Statute number and the licensee was found to be in compliance with the corresponding text of the state Statute out assisted living statutes 144G.08 through of compliance is listed in the "Summary 144G.95. Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 EZ2X11 If continuation sheet 1 of 1 Metro District Office 625 Robert St N, PO BOX 64975 St Paul, MN 55164 Phone: 651- 201- 4500 Food & Beverage Inspection Report Page: 1 Establishment Info License Info Inspection Info Walker Methodist Levande LLC License: HFID 33435 Report Number: F7963251007 2011 6th Lane SE Inspection Type: Full - Single Cambridge, MN 55008 Risk: Date: 5/6/2025 Time: 3:40: 53 PM Isanti County License: Duration: minutes Parcel: Expires on: Announced Inspection: No CFPM: Karen Niles Total Priority 1 Orders: 0 Phone: CFPM #: FM 44295; Exp: 2/7/2027 Total Priority 2 Orders: 0 Total Priority 3 Orders: 0 Delivery: Emailed No orders were issued for this inspection report. Food & Beverage General Comment MET WITH ESTABLISHMENT REPRESENTATIVES KAREN NILES AND JAKE COLLINS ALONG WITH MDH NURSE SURVEYOR SARABETH REMKER. DISCUSSED THE FOLLOWING- -EMPLOYEE ILLNESS POLICY AND LOG -REPORTABLE DISEASES -HIGHLY SUSCEPTIBLE POPULATION RESTRICTIONS -SANITIZERS AND WARE WASH SANITIZING TEMPERATURE REQUIREMENTS THIS IS A COMMERCIAL KITCHEN SPACE. NOTE: All new food equipment must meet the applicable standards of the American National Standards Institute (ANSI). Plans and specifications must be submitted for review and approval prior to new construction, remodeling or alterations. I acknowledge receipt of the Metro District Office inspection report number F7963251007 from 5/6/2025 Karen Niles Peggy Spadafore, MGR Public Health Sanitarian Supervisor 651- 201- 3979 peggy. spadafore@ state. mn. us Metro District Office 625 Robert St N, PO BOX 64975 St Paul, MN 55164 Temperature Observations/ Recordings Page: 1 Establishment Info Inspection Info Walker Methodist Levande LLC Report Number: F7963251007 Cambridge Inspection Type: Full County/ Group: Isanti County Date: 5/6/2025 Time: 3:40: 53 PM Food Temperature: Product/ Item/ Unit: CUT LETTUCE ; Temperature Process: Location: Prep Rail at 38 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: CKD EGGS ; Temperature Process: Location: Prep Rail at 37 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MASHED POTATOES ; Temperature Process: Location: Hot Line at 177 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: STUFFED PEPPERS ; Temperature Process: Location: Hot Line at 198 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MILK; Temperature Process: Location: Walk-in Cooler at 37 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: COLESLAW ; Temperature Process: Location: Walk-in Cooler at 36 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MILK; Temperature Process: Location: BEVERAGE AREA at 40 Degrees F. Comment: Violation Issued? : No Food Temperature: Product/ Item/ Unit: MILK; Temperature Process: Location: MEMORY CARE at 40 Degrees F. Comment: Violation Issued? : No Metro District Office 625 Robert St N, PO BOX 64975 St Paul, MN 55164 Sanitizer Observations/ Recordings Page: 1 Establishment Info Inspection Info Walker Methodist Levande LLC Report Number: F7963251007 Cambridge Inspection Type: Full County/ Group: Isanti County Date: 5/6/2025 Time: 3:40: 53 PM Sanitizing Chemical: Product: Quaternary Ammonia ; Sanitizing Process: Wiping Cloth Bucket Location: Equal To 200 PPM Comment: Violation Issued? : No Sanitizing Chemical: Product: Quaternary Ammonia ; Sanitizing Process: Dispenser Location: Equal To 400 PPM Comment: Violation Issued? : No Sanitizing Equipment: Product: Hot Water ; Sanitizing Process: Location: Dishwashing Area Equal To 167 Degrees F. Comment: Violation Issued? : No Minnesota (MDH) Version Food Establishment Inspection Report Page_ 1_ _ of _1__ EH Manager; RPT: F7963251007 Metro District Office 0 No. of Risk Factor/ Intervention/ Violations Date: 5/6/2025 625 Robert St N, PO BOX 64975 No. of Repeat Risk Factor/ Intervention/ Violations Time: 3:40:53 PM St Paul, MN 55164 Score (optional) Dur: min Establishment: Address: City/State: Zip: Phone: Walker Methodist Levande LLC 2011 6th Lane SE Cambridge, MN 55008 License/ Permit #: Permit Holder: Purpose of Inspection: Est.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident the facility delayed administration of anxiety and pain medications. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. While there was some delay obtaining the resident’s medications upon admission, this delay was caused by confusion in the orders between the hospice provider and the pharmacy. The facility took appropriate steps to address the miscommunication. This medication was to be given as needed (prn). The Pharmacist caught the mistake and contacted the facility to clarify the order. The facility then contacted the hospice RN for the correct order which caused a 36-hour delay in the correct medication being sent to the facility and given to the resident. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted family members and the hospice agency. The investigation included review of medical records, facility records, email communications plus policies and procedures. Also, the investigator observed interactions between staff, residents, and visitors. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s dementia, and history of multiple TIA’s (transient ischemic attack which is a brief blockage of blood flow to the brain). The resident’s service plan included assistance with ambulation, meals, dressing, grooming, medication, and behavior redirection. The resident’s assessment indicated he had wandering behaviors and could get agitated at times. The resident was on hospice prior to admission to the facility and continued hospice services at the facility due to end stage dementia. Upon admission to the facility, the facility had difficulty obtaining his medications including as needed medications. During the admission process the facility nurse and the hospice nurse communicated to understand the roles and responsibilities for the facility and the hospice organization. It was determined the hospice agency would be manage the residents’ medications, which included ordering medications, and changes such as starting or stopping medications. The resident’s medical record indicated the hospice nurse placed orders for the resident’s medications including lorazepam (an anti-anxiety mediation) to be given as needed. However, when the pharmacy received the orders, it was late in the day and most of the medications were sent to the facility early the next day. Unfortunately, the pharmacy required clarification of the lorazepam orders and could not be sent immediately. The pharmacy contacted the facility nurse who subsequently contacted the hospice nurse who provided clarification so the order could be filled by the pharmacy. A review of electronic communication between the between the facility and the hospice provider indicated both took action to address the resident’s medications. During an interview, the facility nurse stated the resident did have some wandering behaviors and did not sleep at night during the first week or so, but this was the resident’s baseline. The facility nurse also stated although the resident did not come to the dining room during this time, he was offered and refused, the staff did bring him food in his room. During an interview, the hospice nurse stated people with dementia often exhibit the types of behaviors the resident did when entering a new and unfamiliar environment as he did upon admission. The hospice nurse stated resident was calm and did not seem agitated when she saw him in-person at the facility so she would not have given the resident an as-needed medication on those occasions. During an interview, the family member had concerns about pain medication not given in a timely manner. A review of email communication regarding the resident’s pain medications indicated hospice addressed updating the resident’s pain medications including morphine and fentanyl patch. The resident’s medication administration record indicated the facility began administering these medications the same day as the email. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No, passed away Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable the Action taken by facility: The facility appropriate action while coordinating cares with the hospice provider. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 08/08/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 33435 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2011 6TH LANE SE WALKER METHODIST LEVANDE LLC CAMBRIDGE, MN 55008 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On June 25, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL334351361C/#HL334352320M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 Z88G11 If continuation sheet 1 of 1